Newsletter: Christmas 2013

Introduction

Welcome to the new format of the Cochrane Consumers and Communication Group Newsletter! From 2014 we hope to deliver e-newsletters every three months, outlining our latest reviews and other activities. We welcome your feedback.

New article

Megan Prictor and Sophie Hill's article on the Consumers and Communication Group's history and the challenges it faces into the future is now available:

Cochrane review training

A big thankyou goes to Steve McDonald of the Australasian Cochrane Centre for delivering training to La Trobe University staff interested in Cochrane systematic reviews, in Bendigo last month. For information on both online and face-to-face Cochrane author training internationally, visit http://training.cochrane.org/

Now on Twitter

The Consumers and Communication Group not only launched a new website in 2013, we also joined the Twitter community. Follow us on twitter @cochraneccrg

A simple online toolkit to help you understand and develop the skills to explore health research. Our straightforward diagrams of systematic reviews are available for re-use under a Creative Commons licence.

Latest reviews

The past few months have been busy for the Review Group. Here are some of our latest Cochrane systematic reviews:

Failure to attend healthcare appointments impacts not only the health of the patients but also health system efficiency. In this review, an update of the original review published in July 2012, we assessed whether sending patients appointment reminders using mobile phone text messaging (Short Message Service (SMS) and Multimedia Message Service (MMS)) could improve attendance.

The review included eight randomised controlled trials published up to August 2012, involving 6615 participants. Four of these trials were newly included in this update.Low to moderate quality evidence included in this review shows that mobile phone text messaging reminders increase attendance at healthcare appointments compared to no reminders and postal reminders, and have the same impact on attendance as phone call reminders. Two studies reported that the costs per attendance of mobile phone text message reminders are less than phone call reminders.

One study reported generally that there were no adverse effects during the study period; none of the studies reported in detail on specific adverse events such as loss of privacy, data misinterpretation, or message delivery failure. The studies included in the review did not report on health outcomes or people's perceptions of safety related to receiving reminders by text message.Further randomised trials are needed to assess the effects of mobile phone messaging reminders for attendance at healthcare appointments.

People define stigma in various ways. In this review we focus on two key aspects of stigma: discrimination (treating people unfairly because of the group they belong to) and prejudice (negative attitudes and emotions towards certain groups). People with mental health problems often experience stigma. It can have awful effects on their lives. Mass media are media that are intended to communicate with large numbers of people without using face-to-face contact. Examples include newspapers, billboards, pamphlets, DVDs, television, radio, cinema, and the Internet. Anti-stigma campaigns often include mass media interventions, and can be expensive, so it is important to find out if the use of mass media interventions can reduce stigma.

We reviewed studies comparing people who saw or heard a mass media intervention about mental health problems with people who had not seen or heard any intervention, or who had seen an intervention which contained nothing about mental ill health or stigma. We aimed to find out what effects mass media interventions may have on reducing stigma towards people with mental health problems.

We found 22 studies involving 4490 people. Five of these studies had data about discrimination and 19 had data about prejudice. We found that mass media interventions may reduce, increase, or have no effect on discrimination. We found that mass media interventions may reduce prejudice. The amount of the reduction can be considered as small to medium, and is similar to reducing the level of prejudice from that associated with schizophrenia to that associated with major depression. The quality of the evidence about discrimination and prejudice was low, so we cannot be very certain about these findings. Only three studies gave any information about financial costs and two about adverse affects, and there were limitations in how they assessed these, so we cannot draw conclusions about these aspects.

Before patients have an operation or other invasive procedure (e.g. endoscopy) it is crucial for the healthcare professional to explain what the treatment involves, what alternatives exist and the risks and benefits of the different treatment options. This process is known as ‘informed consent’ and aims to provide sufficient information to allow patients to understand their treatment options and to choose between them.

Research suggests that when informed consent is obtained, the information provided by healthcare professionals is often unclear or insufficient, leading to misunderstanding, a worse treatment response and even litigation. A number of interventions have been developed to improve the quality of information provided to patients, including written pamphlets, videos and websites. It is unclear whether these interventions work in clinical practice.

In this review we summarise studies of interventions designed to improve information delivery or to improve consideration of information for informed consent.

We searched the scientific literature to identify randomised controlled trials (RCTs) of interventions designed to improve informed consent in clinical practice. We wanted to determine primarily whether these interventions improved all components of ‘informed consent’ (understanding, deliberation and communication of decision). Other individual outcomes of direct relevance to patients (e.g. recall/knowledge, understanding, satisfaction and anxiety), those related to healthcare professionals (e.g. ease of use of intervention, satisfaction) and system outcomes (e.g. cost, rates of procedural uptake) were also assessed.

We included 65 studies involving a total of 9021 patients. The studies varied according to the type of intervention, the procedure for which consent was sought, the clinical setting and the outcomes measured. Most interventions were written or audio-visual. Only one study assessed all the elements of informed consent, but the design was not robust; all other studies assessed only components of informed consent. When the results of multiple studies were combined, we found that interventions improved knowledge of the planned procedure, immediately (up to 24 hours), in the short term (1 to 14 days) and the long term (more than 14 days). Satisfaction with decision making was increased; decisional conflict was reduced; and consultation length may be increased. There were no differences between the intervention and control for the outcomes of generalised anxiety, and either anxiety or satisfaction associated with the consent process.

Limitations of the review include difficulties combining the results of studies due to variation in the procedures undergone by patients, the interventions used and outcomes measured. This means that we are uncertain as to which specific interventions are most effective but pragmatic steps to improve information delivery and consideration of the information are likely to benefit patients.

Past or present consumers of mental health services can work in partnership with mental health professionals in 'consumer-provider' roles, when providing mental health services to others. Their roles may include peer support, coaching, advocacy, specialists or peer interviewers, case management or outreach, crisis worker or assertive community treatment worker, or providing social support programmes. Until now, the effects of employing past or present consumers of mental health services, in providing services to adult clients of these services, have not been assessed rigorously.

We conducted a systematic review, comprehensively searching databases and other materials to identify randomised controlled trials which involved past or present consumers of mental health services employed as providers of mental healthcare services for adult clients. To be included, studies had to make one of two comparisons: 1) consumer-providers versus professionals employed to do the same role within a mental health service, or 2) mental health services with and without consumer-providers as an adjunct to the service.

We found 11 randomised controlled trials involving approximately 2796 people. The quality of the evidence is moderate to low; it was unclear in many cases whether steps were taken to minimise bias, both in the way that participants were allocated to groups, and in how the outcomes were assessed and reported.

Five of the 11 trials involving 581 people compared consumer-providers to professionals who occupied similar roles within mental health services (case management roles (4 trials), and facilitating group therapy (1 trial)). There were no significant differences between the two groups, in terms of client (care recipient) quality of life, mental health symptoms, satisfaction, use of mental health services, or on the numbers of people withdrawing from the study. People receiving care from past or present users of mental health services used crisis and emergency services slightly less than those receiving care from professional staff. Past or present consumers who provided mental health services did so differently than professionals; they spent more time face-to-face with clients, and less time in the office, on the telephone, with clients' friends and family, or at provider agencies.

Six of the 11 trials, involving 2215 people, compared mental health services with or without the addition of consumer-providers. There were no significant differences in quality of life, empowerment, function and social relations, in client satisfaction, attendance rates, hospital use, or in the numbers of people withdrawing from the study, between groups with consumer-providers as an adjunct to professional care and those receiving usual care by health professionals alone. None of these six studies reported on clients' mental health symptoms. None of the studies reported on adverse outcomes (harms) for clients, or on the costs of providing the services.

Overall, we concluded that employing past or present consumers of mental health services as providers of mental health services achieves psychosocial, mental health symptom and service use outcomes that are no better or worse than those achieved by professional staff in providing care.

There is no evidence that the involvement of consumer-providers is harmful. More high-quality and well-reported randomised trials are needed, particularly to evaluate mental health outcomes, adverse outcomes for clients, the potential benefits and harms to the consumer-providers themselves (including a need to return to treatment), and whether it is cost-effective to employ them. Future researchers should include a clear description of the consumer-provider role and relevant training for the role so that it can be readily implemented, and should investigate consumer-providers in settings outside the United States.

Problems may arise when healthcare providers focus on managing diseases rather than on people and their health problems. Patient-centred approaches to care delivery in the patient encounter are increasingly advocated by consumers and clinicians and incorporated into training for healthcare providers. We updated a 2001 systematic review of the effects of these training interventions for healthcare providers that aim to promote patient-centred care in clinical consultations.

We found 29 new randomized trials (up to June 2010), bringing the total of studies included in the review to 43. In most of the studies, training interventions were directed at primary care physicians (general practitioners, internists, paediatricians or family doctors) or nurses practising in community or hospital outpatient settings. Some studies trained specialists. Patients were predominantly adults with general medical problems, though two studies included children with asthma.

These studies showed that training providers to improve their ability to share control with patients about topics and decisions addressed in consultations are largely successful in teaching providers new skills. Short-term training (less than 10 hours) is as successful in this regard as longer training. Results are mixed about whether patients are more satisfied when providers practice these skills. The impact on general health is also mixed, although the limited data that could be pooled showed small positive effects on health status. Patients' specific health behaviours show improvement in the small number of studies where interventions use provider training combined with condition-specific educational materials and/or training for patients, such as teaching question-asking during the consultation or medication-taking after the consultation. However, the number of studies is too small to determine which elements of these multi-faceted studies are essential in helping patients change their healthcare behaviours.